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SAN JOAQMM COU01TY <br />ENVOONMENTAL HEALTH MARTMEW <br />6: East Hazelton Avenue, Stockton, California <br />V i f <br />i # 1 ' : ♦ r+ z, ! # M 'Y .': .. i *ItI911 <br />.... a r r w <br />Inspection r# <br />Note.- staff associated k tocomply byabovenoted datesbe <br />billedat the currenthourly <br />For this s:tion to ;:: <br />r r the operator of the site must Include: <br />i. statement documenting correctiveactionse taken i ill betakenfor of Yi; <br />verifying* Copies of sample results/manildsts/training recordslother appropriate paperwork, and/or photos <br />corrections <br />Operates certification <br />Inspection Inspected <br />Facility iii • + :D# <br />cedify <br />under penalty i <br />1. 1 have corrected the violations specified In the Inspection Report from the o4ove-mentioned <br />Inspection date. <br />2. 1 have personally examined the follovAng documentation submilted as proof of compliance FOR <br />EACH VIOLATION 1:. believe the informationto be true, accurate,complete: <br />Photos <br />—Statement <br />am authorizy # o submit cerfilication on behalf of Respondent. <br />4. 1 am aware that there am significant penalties for submitting false Information, Including the <br />possibility of a fine andfor imprisonment for known violations. (HSC25191) <br />A u <br />Signature: <br />Date: <br />